TCCC
ATLS
“CAB” – hemorrhage control before airway assessment
“ABC” – airway, breathing, circulation assessment
Incorporates situation into medical decision making (see Table 41.2)
Does not take into account scene safety/tactical situation
Encourages the use of hemostatic dressings and tranexamic acid
Does not mention hemostatic dressings or tranexamic acid
Encourages the use of tourniquets for severe hemorrhage
Discourages tourniquets and espouses direct pressure
Allows for “hypotensive” or “damage control” resuscitation
Calls for 1–2 l of crystalloid to treat hypotension
Encourages the use of nasopharyngeal airway
Encourages the use of endotracheal intubation
Allows to enteral pain medication administration and the use of nonnarcotic parenteral pain medications
Only encourages parenteral opioid medication
Does not encourage spine immobilization for most mechanisms of injury and considers tactical situation in decision to utilize spine immobilization
Encourages the use of a cervical collar and spine board for many blunt mechanisms of injury
Addresses importance of early antibiotic administration for severe extremity and abdominal wounding
Does not address role of antibiotics in initial trauma care
The implementation of Tactical Combat Casualty Care has been one of the major factors in reducing preventable death on the modern battlefield from approximately 14% in Vietnam to 8% during Operation Iraqi Freedom (OIF ) and Operation Enduring Freedom (OEF ). In a memorandum dated 6 August 2009 and as supported in 2 studies, the Military Defense Health Board (DHB) noted that several Special Operations units in which all members were trained in TCCC reported no incidents of preventable battlefield fatalities during the entirety of their combat deployments. Given the simplicity of training and this high rate of efficacy, TCCC training is now recommended for all deploying combatants and medical department personnel.
Given the proven success of TCCC on the battlefield, the civilian medical community began to examine closely the tenants of the TCCC doctrine and, driven by prehospital training programs, to integrate portions into civilian trauma care. In fact, many civilian emergency medical system agencies began to simply incorporate TCCC into their operations. Others, however, have resisted implementation of TCCC , citing concerns about military language and operational concerns regarding difference in patient populations, resource limitations, and legal constraints. Given these differences, the issue of the direct applicability of TCCC for civilian operations has been discussed and challenged in many operational medical circles.
Examination of the civilian high-threat medical operations, especially with the “all-hazards” approach necessitated by the wide variety of civilian operations, quickly finds that there are a multitude of scenarios and considerations which are not addressed in the objectives or scope of TCCC . Characteristics that distinguish civilian from military high-threat prehospital environments include, but are not limited to, the following:
Scope of practice, liability, and differences/breadth of medical care protocols
Patient population to include geriatrics, pediatrics, pregnancy, and special needs
Differences in barriers to evacuation and care
Differences in baseline health of the population
Differences in wounding patterns and use of protective gear
Chronic medication use in the injured
Equipment acquisition and budgetary restraints
From TCCC to TECC
Given the gap in civilian high-threat medical response, a group of voluntary subject matter experts in emergency medicine, trauma surgery, critical care medicine, anesthesiology, pain management, EMS, law enforcement, tactical medicine, and medical education founded an independent nonprofit (501c3) organization called the Committee for Tactical Emergency Casualty Care (C-TECC ) in 2011. Using the foundation of the military TCCC guidelines, C-TECC created the Tactical Emergency Casualty Care (TECC ) guidelines as a best practice, evidence-based operational medical care framework that balances the threat, varying scope of practice of responders, differences in patient population, limits on medical equipment, and variable availability of resources that may be present in all high-threat atypical emergencies and mass casualties in the civilian setting. Additional goals of TECC include establishing a framework that balances risk-benefit ratios for all civilian operational medical response elements, providing guidance on medical management to mitigate preventable deaths at or near the point of wounding, and minimizing provider risks while maximizing patient benefits. Overall the concepts and medical approach of TECC are similar to TCCC , but the developmental considerations, language, and scope of application have been adapted to the various needs of the civilian sector (Table 41.2). Additionally, the ongoing evidenced-based analysis of the TECC guidelines and the annual updates to the guidelines are firmly founded in civilian medical evidence. Since inception in 2011, TECC has been endorsed by a number of professional and governmental entities and has been included in a wide number of federal operational guidance documents.
Table 41.2
Differences between TCCC and TECC
TCCC | TECC |
3 phases of care: 1. Care under fire 2. Tactical field care 3. Tactical evacuation | 3 phases of care 1. Direct Threat (Hot Zone ) 2. Indirect Threat (Warm Zone) 3. Evacuation Care (Cold Zone) |
Separates skill/knowledge for: 1. Soldier/sailor 2. Medic 3. Physician | Separates skill/knowledge for 1. First Care Provider 2. First responder with a duty to act 3. EMR/EMT 4. Paramedic 5. Physician |
Does not address extremes of age | Addresses all ages, pediatrics to geriatrics |
Restricted to a uniform methodology | Allows for variability in practice based on jurisdiction and state scope limitations |
Tenets of TECC
Decreasing the time from injury to initial stabilizing care has been defined as the most critical step in mitigating preventable trauma fatalities. Dr. Nicholas Senns, the founder of the Association of Military Surgeons, wrote in 1891 that, “the fate of the wounded rests in the hands of one who applies the first dressing.” A century later, this concept was translated to the Platinum 10 min and the Golden Hour as a way to define the importance of the rapid initial care and stabilization of the traumatically injured patient; thus simple, stabilizing care at or near the point of wounding is at the foundation of TECC .
At most basic level, TECC balances the operational threat against the need for medical care for the wounded in a risk-benefit matrix. As compared to a standard prehospital trauma scenario (e.g., a few patients with plentiful resources), there are significant differences that must be accounted for when addressing medical care in a hostile scene where patients outnumber resources, and/or scene security cannot be guaranteed. As such, TECC recommends organizing these tactical situations into phases of care defined by the threat itself: Direct Threat (Hot Zone ), Indirect Threat (Warm Zone), and Evacuation (Cold Zone). Within each phase, the feasibility and utility of medical interventions change based upon the risk of further injury to the patient or provider.
Throughout all phases of care, TECC stresses the importance of immediate hemorrhage control followed by simple airway and breathing management, hypothermia prevention, and damage control resuscitation. Therefore, TECC strongly espouses the use of direct pressure, tourniquets, wound packing, and pressure dressings and hemostatic dressings and the use intravenous medications such as tranexamic acid based on the skill level and scope of practice of the responder. TECC also encourages the use of all possible care providers, including first care providers (formerly known as civilian bystanders), while taking into account the tactical situation and scene safety.
Direct Threat (Hot Zone )
A Direct Threat or Hot Zone is any dynamic area where the risk of harm to the patient or provider is imminent and may be greater than the risk of death posed by the injury itself. This may be a static geographically defined area with perimeters such as seen in traditional hazardous materials or police tactical response, but the Hot Zone may also be dynamic and shifting with fluid boundaries. Direct Threat (Hot Zone) phase applies for, but is not limited to, active shooter situations, immediately dangerous to life and health (IDLH) environments (e.g., hazardous materials spills, fire scene, unstable structural collapse, etc.), close proximity to unexploded improvised devices, and other technical rescue and mass casualty situations. The majority of effort during this phase is directed at mitigating the threat and extricating those in danger from the threat area. As such, very limited medical care is provided during this phase of care due to the likelihood of incurring additional casualties as a consequence of both redirecting resources away from threat mitigation to providing patient care as well as of spending more time within close proximity of the threat.
It is important to note, and is emphasized during this phase, that accessing and extricating the patient from an area of threat should be considered a medical intervention and prepared for by trained first responders. “It is no longer acceptable to stand and wait for casualties to be brought to the perimeter” because “external hemorrhage control is a core law enforcement skill.” As such, joint training and integration of resources between police and fire/EMS prior to an actual event is pivotal to allow for the rapid deployment of escorted and protected medical assets, often referred to “Rescue Task Force” units, into areas of high threat.
During Direct Threat (Hot Zone ), external hemorrhage control is the only medical intervention that is recommended, through the rapid application of tourniquets only if the hemorrhage is considered so severe that it is likely the patient will exsanguinate prior to immediate evacuation to a safer area. Given the need to limit time spent in proximity to a threat, direct pressure should be applied immediately and followed quickly by tourniquet application as high up on the extremity as possible. These tourniquets should be placed over any clothing present to minimize time to application and control of bleeding. If tourniquets are not available and the injured person is capable, he or she should be instructed to apply direct pressure to his or her own wound during evacuation. The use of wound packing, pressure dressings, and hemostatic agents for hemorrhage control is deferred to later phases of care due to the amount of time and need for specialized equipment and training required to properly apply these interventions. All other medical interventions are deferred to later phases of care.
Indirect Threat (Warm Zone)
Indirect Threat (Warm Zone) care begins once the patient and provider are in an area where there is still the potential for harm, or there is a chance that the dynamic situation may deteriorate back to a Direct Threat situation. Because of the dynamic and changing nature of high-threat environments, the care provider must maintain constant situational awareness and adjust the treatment strategy as appropriate. Examples of Indirect Threat (Warm Zone) include an active shooter event where a particular room/corridor has been cleared by law enforcement, but the assailant him/herself has not yet been neutralized; the immediate aftermath of an exploded improvised explosive device involving multiple wounded patients in need of care and rescue, but the risk of a secondary or delayed explosive device remains; or industrial accident where the possibility of further structural collapse or recurrent event is not likely but has not been definitively ruled out.
Operational mitigation of the threat and safety considerations for responders remains paramount; however, in this phase, patient assessments and treatments are more comprehensive and methodical. As with all considerations in TECC , Indirect Threat (Warm Zone) medical interventions remain primarily focused on rapidly correcting any of the potentially preventable causes of death, preventing further medical complications, and evacuating the patient to a safe area and definitive care. Several common acronyms are used to aid providers in recalling the correct order to address potentially preventable causes of death, but the most common for prehospital medical personnel is MARCHE: Major Hemorrhage Control, Airway Management, Respiratory Management, Circulation Control/Shock Management, Head/ Hypothermia Prevention, Everything Else (Table 41.3). Another common one for providers with a more limited scope of practice is SCAB-E: Situational awareness, Circulation/bleeding control, Airway management, maintenance of Breathing, and Evacuation/Everything Else.
Table 41.3
MARCHE skills
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